 Good afternoon here, morning in Oxford and I'll be giving a short talk on how using process mapping to understand patient journeys through hospitals. So I'll give a brief introduction and then just give an example how to do the patient journey talk briefly about the ways in healthcare, and then give a couple of examples from our current work it's ongoing. So I'm just giving like preliminary findings were not done with analysis, but just to illustrate how we've used patient journeys process mapping to understand patient journeys and then a summary. So by way of introduction process mapping is a form of clinical audit, and it allows us to see the patient's experience by following the sequence of steps as they receive care. It helps to identify potential blind sports bottlenecks and other inefficiencies in the provision of care with and can help improve quality of care increase efficiency and improve overall patient satisfaction. By way of interventions can help redesign and streamline and work flows. So there are various approaches used in process mapping. You could have the option of a multidisciplinary meeting where you have around four to five clinical staff who are involved in provision of care, especially for the particular condition that you're studying. They either have a single or short series of meetings, preferably in a non clinical environment. The advantages of this is that you can get results in a defined time, and then allows interaction because they can talk amongst each other use postage as they chat out the journey as they understand it. Now this usually depends on their knowledge of the patient journey, and there's an absence of direct observation. The other approach is walking the journey. So following the normal route of the patient journey, having one to one patient and staff interviews in the clinical environment and it allows a realistic assessment of the journey, particularly if you can do it several times. And you have the direct observation where you can actually note what's happening. So the effectiveness is influenced by the availability of staff time and even the researcher time because you actually have to be there in real time as things are happening. And also dependent on how open the staff and patient are. And then so there's that the walking the journey and then this direct observation whereby you follow a patient's journey in real time with direct observation and then informal chats with them as you observe what's going on. And this provides information from the patient's perspective on the journey. The other, the previous two, you're sort of getting the health worker perspectives. So this again is also time consuming and influenced by day to day variations in clinical environments and even the type of patient you select so you make an assumption that what you're observing to be is what to typically happen on other days. And then the final example is a patient self reported experience where they sort of journal and record the experience of their journey in real time. And this represents the experience from their perspective. And this also depends on the type of patient you select and what the expectations are, and you may end up missing those were probably too elderly to seek to frail or maybe retreat to be able to document their story. So ideally how to map this journey so you start by talking to the clinicians and patients, if you're able to list the steps and activities involved in a particular treatment process as they understand it. And then go on to get more detailed information about the patient journey from the experiences and with this information you start to map out the different parts taken by the patients when they in the system. And then the analysis is where now you sit down and carefully reflect preferably with the staff if possible on where potential gaps are and non value steps, not how many steps it takes for a patient to get from one particular point to the end stuff interactions. What's the time taken for each step that's the task time. And then what's the time between each step that's the way time, and how many times is the patient passed on from one person to another, that's the handoffs. And then what do patients and staff complain about. So various ways that maybe identified maybe like prescription errors, inappropriate scheduling distance between related departments in one of in one of our study hospitals we found the hospital is quite big that it depends on the relatives being able to drive from one department to another. And those are often using taxi or border border, and then waiting time by patients or staff inventory issues, poor economics of a processing meaning there's so much paperwork to be done for simple tasks, and then not making the most of staff skills so all this should be at the back of your mind as as you're trying to think through this channel. So, I just have a couple of examples from actual patient journeys we've done and we started off by interviewing healthcare workers who take care of critically ill patients and having them reflect for example. From the time a patient arrives in the emergency department up to the time when they're either being referred or being admitted. So you can see the steps listed there this particular activity had around 24 steps, and you can see the bottlenecks they could identify. For example, like at registration and payment of registration fee, and then waiting for various things waiting for radiology to be done, waiting for interpretation of results, then waiting to be reviewed by the doctor with results, then waiting for availability of bed space so, and then asking the staff at that time to try and reflect how long each of these activities would take. And then this is an excerpt from a transcript that of an actual patient that research assistant was able to follow from start to processing. This particular patient was an adult female patient she was brought in at the end accompanied by two relatives in obvious pain and distress. She was put in the bed and was being observed by a nurse and clinical officer, and the nurse went on to take the initial vital signs, and the oxygen saturation was around 93% and her heart rate was 90. So you can see the person collecting the data was able to observe the actual equipment that are there and the number of staff was there, and the activities, immediate activities that were being done like fixing an IV line. And then the clinician made a request for blood test. So the patient was in the bed. So that was 1020 so 20 minutes later vital signs were repeated, and they noted that the blood pressure was 93 out of 50 so this is low for an adult. And what the nurse did at that point was to start a drip of name normal sailing. The patient was still in the bed with the fluids running remember a request for blood test has been done. So the relatives have been told they need to go make payments for the blood sample to be done. So that seems to take a while the fluids are running while the relatives are trying to go make the payments so this is like just over an hour since they arrived. So they come back later at 12 or 4 so that's like an hour and a half later, the sample is taken to the lab fluids are still running, and the blood pressure is still low. And at this point they also note that the patient is pale, and they are waiting results from the lab. So, patient came at 1020 so around 1245 the medical officer who was slightly senior to the clinical officer now reviews the patient and decides that they need an ultrasound of the abdomen and the pelvis to determine why she could be in pain and distress. The fluids are still running and now the relatives have been told they need to go pay for the radiological tests. So, so the patient is being willed to the radiology department remember they came at 1020 it's now around 114. She's accompanied by her relatives and they have to go through the same cycle again now paying for the ultrasound to be done, and they are waiting in a queue. Remember she's accompanied by her relatives, not by clinical staff, when they eventually gets in nearly an hour later by the radiologist, they've paid they're told the ultrasound can be done. Since the patient should have fasted before the test is done. So they go back to the outpatient department. This is nearly an hour later, and the doctor insists that the test is urgent and it needs to be done. So she gets willed back by her relatives to the radiology. The test has not been done. Radiology say they want to clear communication from the agency so they go back. Another hour has gone. So the doctor writes on the file that the test is urgent and it needs to be done as soon as possible. So they're willed back again. And the test still has not been done by 215. Remember. So the doctor makes a decision that don't do an abdominal pelvic just do of the abdomen alone. So they go out into the radiology. It's now 225. And they're waiting for the now the abdominal ultrasound to the pelvic ultrasound to be done. She's told she needs a full bladder. So she's has to drink water. She's waiting. It's now three o'clock. She's still waiting. 520. She's still waiting. Next in line. Remember in all this time, there's no one who's checking her vitals again, or replacing her fluids or checking her condition. She's just been waiting. So she gets there just close to six o'clock. That's when the ultrasound is done. And now she has to go back to casualty waiting to be reviewed with the radiology. At this point, whoever's been observing has not seen much in the way of review because everyone is waiting for investigation results to be done. The person observing left and did a follow up call the next morning and found out that the patient eventually was admitted in the dining ward around 1030. And had a diagnosis of a rapture, the topic pregnancy, and had to go to a theater for an urgent surgical intervention. So this just illustrates the back and forth and the circularity that patients have to go through, often by themselves, needing relatives to navigate the systems. And even though she was quite sick, she was pale, her vitals were deranged with low blood pressure, there was no ongoing monitoring, and people were waiting to review her with results. So this just illustrates how you can quickly identify where these patients may actually deteriorate and even worse outcomes can happen. And then this other chart shows now when you sit down to start to visualize the processes and trying to identify decision making steps and bottlenecks and where unnecessary steps are. So that's where we're supposed to be proceeding to next before we try and come up with recommendations. So process maps start ugly, but they're very practical, and they can end up as powerful communication tools. And like I said, there are various ways of doing them, as long as you understand how and why. And they can be a great starting point for quality improvement. It's important to work together with the staff for ownership and accountability. They are easy to understand and they communicate clearing inefficiencies and they can help plan simple or low cost strategies like workflow redesign. So I'll stop there. And just a couple of references in case you're thinking about doing process mapping for yourselves for your work. Thanks, Susie.